Form Library

Everything you need in one place.

Below you’ll find links to information and forms, which you can view or download and print.

If you prefer talking with a HealthEZ representative, call 1-844-302-7781

LivEZ Challenges
 
The 150 Challenge Focus on physical activity for 150 minutes each week! Staying active is so important to your physical and mental health. This will help track your activity & time.
Drink Up Challange Your body is 60% water! Water is critical for your body to function at its best. This will help track your intake of 10 cups of water every day for 4 weeks.
Relaxation Challenge Each week you will be challenged to try different techniques. There are spots for notes at the bottom of each page to write down observations you may have.
Bingo Challenge Participate in at least one daily challenge for the next 5 weeks, marking off each square as you complete the challenge.
Medical Benefit Information
 
Benefit Overview Provides a high level overview of your medical benefits.
Enrollment Form This form is to be filled out if electing medical benefits.
Healthiestyou Healthiesyou offers unlimited access to a licensed doctor right from your phone.
PPO Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
HSA 1 Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
HSA 2 Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Summary Plan Description Provides information on how the medical plan operates, when employees are eligible for benefits, how services and benefits are calculated, when benefits become vested, when and in what form benefits are paid, how to file claims for benefits, and much more.
Prior Authorization Check Check this list to see which services DO NOT require Prior Authorization.
Pharmacy Benefit Information
 
CVS/Caremark Home Delivery Service Overview Provides on overview on the benefits of CVS/Caremark Home Delivery Service.
CVS/Caremark Home Delivery Service Guide Provides information on how to use CVS/Caremark Home Delivery Service.
CVS/Caremark FAQ Frequently asked questions about CVS/Caremark Prescription Benefits and Home Delivery Service.
CVS/Caremark Home Delivery Service Form Use this form for mail order prescriptions from CVS/Caremark.
CVS/Caremark Website Guide Provides information on how to use the CVS/Caremark website.
CVS/Caremark Mobile Application Provides information on how to use the CVS/Caremark mobile app.
Medicare Part D Notice This notice has information about your current prescription drug coverage and about your options under Medicare’s prescription drug coverage.
Important Notices
 
Notice of Electronic Disclosure Notice of Electronic Disclosure of Employee Benefit Notices, Summary of Plan Description, and Plan Amendments.
Paper Employee Notice Acknowledgement of Paper Employee Benefit Notices.
COBRA Notice Explains your right to continue health benefits, if you were to lose them through your group health plan.
Special Enrollment Notice Explains your right to enroll in your group health plan, if you lose your "other" health coverage.
Children´s Health Insurance Program (CHIP) Notice Explains how your eligibility for Medicaid or CHIP may qualify you for premium assistance to pay for your employer's health coverage.
Newborn Act Notice Explains important protections for mothers and their newborn children.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Notice. Explains how medical information about you may be used and disclosed.
The Genetic Information Nondiscrimination Act (GINA) Booklet Explains how discrimination on genetic information is prohibited in group health plan coverage.
Women´s Health and Cancer Rights Act of 1998 Explains important protections for those who choose to have breast reconstruction, in connection with a mastectomy.